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Insurance Company Appeals

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1 Insurance Company Appeals on Wed Dec 07, 2011 1:17 pm

Mantha

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Has anyone on this board ever appealed an insurance company decision? In this case, I'm talking about Sun-Life.

Here's a quick version of my story
-my wife did some damage to her discs in her back last year.
-her incompetent GP* labeled it as a 'mystery illness', recommended pain killers.
-a doctor friend in the US was shocked to find out the incompetent GP didn't do an MRI.
-8 months later, the MRI reveals annular tears in discs, which are
leaking fluid that aggravates her nerves. (in a different way than -I-
aggravate them! lol)

We put in a claim to Sun life, who paid short term disability, but refused to pay long term. At that point, the only diagnosis we had was "mystery illness", which let's be honest, isn't covered by insurance.

The tears were eventually properly diagnosed a few months later. Still, I feel like Sun Life is giving us the runaround.

Is there an Insurance Ombudsman or anything? Or do I have to get a lawyer. Subsequently, how stupid do I have to be to think I can sue an insurance company and win?

*Oh, and the GP truly is incompetent. He dismissed the fact that my
wife had a fairly visible SIXTEEN LITRE, THIRTY SIX POUND CYST in her abdomen a few years ago.

http://yaciuk.blogspot.com

2 Re: Insurance Company Appeals on Wed Dec 07, 2011 1:45 pm

Deank

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contributor eminence
contributor eminence


_________________
Why do we call them fingers if no one has ever seen them fing?

3 Re: Insurance Company Appeals on Wed Dec 07, 2011 1:48 pm

Deank

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contributor eminence
contributor eminence


_________________
Why do we call them fingers if no one has ever seen them fing?

4 Re: Insurance Company Appeals on Wed Dec 07, 2011 1:48 pm

Deank

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contributor eminence
contributor eminence
When you have a concern or complaint

Sun Life Financial's Customer Complaint Process


Complaints do arise from time
to time -- you may feel you've been dealt with unfairly, or perhaps
there's been a misunderstanding. Whatever the nature of your concern,
we'll treat it professionally, confidentially and courteously. As a
valued customer, this is what you expect, and deserve.



Working with you on these
matters also presents an important opportunity for us to make
improvements that could enhance the customer service experience for
everyone doing business with us.



Here's how our Customer Complaint Process works


If you have a complaint or
concern about a product or service from one of the Sun Life Financial
group of companies in Canada, you can address the situation by following
the steps below:



Step 1: Let us know

Discuss your concerns with
your advisor or with the appropriate customer service team at head
office. Often, a simple correction or explanation by these front-line
people can quickly resolve the problem.



Here's how to contact our customer service teams at head office:


(for faster service, please provide your policy or contract number and your member ID or certificate number for Group plans)
By phone

By e-mail


(Internet e-mail is not a secure method of communication)

Group Benefits
1 800 361-6212

Can_GroupBenefits@sunlife.com
Association & Affinity Groups
For claims-related questions:
1 800 361-6212



For all other inquiries:
1 800 669-7921



or (416) 408-7390 in Toronto

Can_AssocAndAffinity@sunlife.com
Public Service Health Care Plan (PSHCP) and Pensioners' Dental Services Plan (PDSP)
1 888 757-7427
or (613) 247-5100 in the Ottawa area

Can_OttawaService@sunlife.com
Individual Insurance and Investments
1 877 SUN-LIFE (786-5433)

service@sunlife.com
Group Retirement Services
(e.g. Group RRSP, DCPP, DPSP)
1 800 387-2636

Can_PenControl@sunlife.com
General question or comment
1 877 SUN-LIFE (786-5433)

Webmaster@sunlife.com


Step 2: Escalate your complaint within the business area

If you are not satisfied with
the outcome of Step 1, ask to whom you can escalate your complaint.
Each business area at Sun Life Financial has a defined complaint
handling process. Depending on your product or service, you will be
referred to a team leader, supervisor, manager or consultant who will
review your complaint with a fresh set of eyes.



Step 3: Contact the Ombudsman's Office

If you are still not satisfied after following the previous steps, you can contact the Sun Life Financial Ombudsman's Office:


By mail:Ombudsman's Office
Sun Life Financial
225 King Street W.
Toronto, ON M5V 3C5
E-mail:ombudsman@sunlife.com
Fax:416-595-1431 or 514-866-2548

The Ombudsman's Office does
not review complaints that have not yet been through Steps 1 and 2, so
you'll want to indicate who you've already contacted, and why you
disagree with their decision.



After the Ombudsman's Office
review, you'll receive a written response, except in some cases where a
simple problem can be cleared up quickly and to your satisfaction over
the phone. Most investigations are completed within 30 days of
receiving your complaint and all supporting information. If this
deadline cannot be met, we will contact you to let you know why the
extra time is necessary and when you can expect a response.



The written response from the
Ombudsman's Office is considered Sun Life Financial's final position on a
complaint. Unless you present any new and relevant information that
was not previously reviewed, your complaint will not be reopened.



Step 4: External recourse options

If you remain dissatisfied
with the Ombudsman's Office's final position and wish to pursue your
complaint further, there are several regulatory and industry bodies
available to you free of charge, depending on the product or service
involved and your province of residence. These third parties will
usually decline to review your complaint until after the Ombudsman's
Office has reviewed it. If your unresolved complaint is eligible for
further review externally, the Ombudsman's office will provide you with
detailed contact information for the appropriate third party(ies) in its
final position letter.



For complaints about...External recourse option


  • life and health insurance - individual and group
  • an advisor's conduct (except for mutual funds)
  • trust company products and services
  • annuities
  • Group Retirement Services and pension products

The OmbudService for Life & Health Insurance (OLHI) is
part of the Financial Services OmbudsNetwork (FSON), a national
industry-based dispute resolution system for consumers of financial
services. The OLHI deals with concerns about life and health insurance
products and services that have not been resolved through the company's
dispute resolution system. Information about the OLHI is available on
their website at www.olhi.ca.

OLHI's mailing address is:

OmbudService for Life & Health Insurance
401 Bay Street, Suite 1507
P.O. Box 7
Toronto, ON M5H 2Y4
...a mutual fund account or a mutual fund dealer or representative (Sun Life Financial Investment Services Inc.) -- outside QuebecThe Mutual Fund Dealers Association of Canada (MFDA)
is the national self-regulatory organization for the distribution side
of the Canadian mutual fund industry (excluding Quebec). The MFDA's
primary focus is on compliance and enforcement rather than customer
compensation. You can find out more about the MFDA from their website
at www.mfda.ca.

MFDA's mailing address is:
121 King Street West, Suite 1000
Toronto, ON M5H 3T9



and/or


The Ombudsman for Banking Services and Investments (OBSI)
is part of the Financial Services OmbudsNetwork (FSON), a national
industry-based dispute resolution system for consumers of financial
services. The OBSI deals with concerns about banking services and
investments that have not been resolved through the company's dispute
resolution system, and may recommend compensation if it determines that a
customer has been treated unfairly. Information about the OBSI can be
found on their website at www.obsi.ca.



OBSI's mailing address is:
Ombudsman For Banking Services and Investments
401 Bay Street, Suite 1505

P.O. Box 5
Toronto, ON M5H 2Y4

for Quebec residents only: ...all products and services, including mutual fund dealers or representativesThe Autorité des marchés financiers (AMF) is
the body mandated by the government of Quebec to regulate the
province's financial markets and provide assistance to consumers of
financial products and services. At any time after Step 2 of our
Customer Complaint Process (but preferably after Step 3), you can ask
Sun Life Financial to send a copy of your complaint file to the AMF by
completing a Request for the Transfer of a File form. This form, and
other information about the AMF, is available on their website at www.lautorite.qc.ca/index.en.html.

The AMF's mailing address is:
L’Autorité des marchés financiers
Place de la Cité, Cominar Tower
2640 Laurier Boulevard, suite 400
Québec, QC G1V 5C1
...federal consumer provisions.


Among the consumer provisions that apply to life and trust companies are those requiring them to:




...and requirements for them to provide consumers with information about:



  • interest and charges applicable to deposit accounts (not applicable to insurance policy loans)
  • how to contact the FCAC when they have a complaint about the company's compliance with a consumer provision.

The Financial Consumer Agency of Canada (FCAC) supervises
federally regulated financial institutions to ensure they comply with
federal consumer protection laws (or "consumer provisions"). The FCAC
focuses on compliance and enforcement, and does not provide compensation
or get involved in individual disputes. For more information about the
FCAC, including a complete listing of consumer provisions that apply to
Sun Life Financial's insurance and trust companies, please visit the
FCAC's website at www.fcac-acfc.gc.ca.

FCAC's mailing address is:
Financial Consumer Agency of Canada
427 Laurier Avenue West, 6th Floor
Ottawa, ON K1R 1B9


_________________
Why do we call them fingers if no one has ever seen them fing?

5 Re: Insurance Company Appeals on Wed Dec 07, 2011 2:52 pm

grumpy old man

avatar
administrator
administrator
Who provided the Sun Life coverage? If a company is involved, one that Sun Life would not want to aggravate, try appealing through them...


_________________
Yes, I really am that Grumpy...

It's their, they're and there; in Canada it's colour, cheque, rumour and zed...

6 Re: Insurance Company Appeals on Wed Dec 07, 2011 7:51 pm

rosencrentz

avatar
uber-contributor
uber-contributor
Insurance companies will deny any claim that they can. In your case DeanK has given you all the avenues to follow.

Over the years I have had several cases where going to court to collect what I had been insured for was a necessity.

One major theft, was claimed to be a "mysterious disappearance , discovered upon taking inventory", which wasn't the truth!

I hired a Jewish lawyer, always recommended, and did collect. I think there was a $2-$3000 bill .

Another flood claim, I had a real problem collecting because the insurance companys adjuster was a real dick head. I hired my own adjuster and the reason the dick head was being a dick head came out at a meeting, after I was yelling at the dick head!


_________________
They cut my back open ! Help!
http://www.elansofas.com

7 Re: Insurance Company Appeals on Thu Dec 08, 2011 2:07 pm

Mantha

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contributor plus
contributor plus
Thanks, everyone! This is EXACTLY the type of responses I was looking for! Much to go through!

http://yaciuk.blogspot.com

8 Re: Insurance Company Appeals on Fri Dec 09, 2011 2:03 pm

rosencrentz

avatar
uber-contributor
uber-contributor
If your insurance company hasn't got an update on the cause , that is why they are denying the claim.



Remember , you can hire an independant asjuster to deal with your company, but from their posted ways of moving forward, it appears that you have the opportunity to get the claim fixed.

Good luck!


_________________
They cut my back open ! Help!
http://www.elansofas.com

9 Re: Insurance Company Appeals on Wed Dec 14, 2011 7:25 pm

Guest

avatar
Guest
I treat everything that comes from an insurance adjuster as a outright lie. Go from there.

10 Re: Insurance Company Appeals on Thu Dec 15, 2011 4:50 am

rosencrentz

avatar
uber-contributor
uber-contributor
Whomever is paying the adjuster is who he/she is working for, and where their loyalties are.


_________________
They cut my back open ! Help!
http://www.elansofas.com

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